Elsevier

Social Science & Medicine

Volume 119, October 2014, Pages 18-26
Social Science & Medicine

Healthcare system and the wealth–health gradient: A comparative study of older populations in six countries

https://doi.org/10.1016/j.socscimed.2014.08.013Get rights and content

Highlights

  • Study examines wealth–health gradient across healthcare systems of Sweden, U.K., Germany, Czech Republic, Israel, U.S.

  • In all six countries – wealth is likely to increase health.

  • Healthcare system type is likely to affect overall health.

  • Wealth–health gradient – largely independent of income.

  • In the U.S. the wealth–health gradient is significantly different and much greater than that in the other five countries.

Abstract

The present study provides a comparative analysis of the association between wealth and health in six healthcare systems (Sweden, the United Kingdom, Germany, the Czech Republic, Israel, the United States). National samples of individuals fifty years and over reveal considerable cross-country variations in health outcomes. In all six countries wealth and health are positively associated. The findings also show that state-based healthcare systems produce better population health outcomes than private-based healthcare systems. The results indicate that in five out of the six countries studied, the wealth–health gradients were remarkably similar, despite significant variations in healthcare system type. Only in the United States was the association between wealth and health substantially different from, and much greater than that in the other five countries. The findings suggest that private-based healthcare system in the U.S. is likely to promote stronger positive associations between wealth and health.

Introduction

Social scientists have long demonstrated that wealthy people tend to be healthier and live longer than poor persons (Kawachi et al., 1997, Wilkinson and Pickett, 2006). The positive association between economic resources and health (usually referred to as “health gradient”) can be attributed to two reasons. First, economic resources can be used to purchase better healthcare services (e.g., Van Doorslaer et al., 2006). Second, poor health may lead to a depletion of economic resources (e.g., Smith, 2005). While both approaches are logical and quite convincing, they are by no means contradictory.

To date most cross-national studies have focused on the association between economic well-being and health, showing that the average health of a population is likely to rise with economic growth (e.g., Hurd and Kapteyn, 2003) and to decline with higher inequality (e.g., Pickett and Wilkinson, 2007). However, only few studies have systematically investigated the extent to which the wealth–health gradient differs across countries (e.g., Avendano et al., 2009, Semyonov et al., 2013) and none have examined whether the wealth–health gradient varies in magnitude across different types of healthcare systems using individual-level data. The data for this study consist of six national samples of populations fifty years of age and over. The comparative analysis enables to delineate the relationship between wealth and health and to better understand whether healthcare system types affect the association between wealth and health.

The contribution of this research is twofold. First, it provides a cross-national comparative study of the link between different healthcare system types and overall population health. Second, it examines, for the first time, the extent to which the association between wealth and health among older adults differs across countries, and ascertains whether the type of a nation's healthcare system is tied to this association. Thus, this research not only advances theoretical knowledge in the fields of health and gerontology, but also gives initial insights into the ways in which health policies affect wealth–health inequality.

Section snippets

Wealth–health gradient

A plethora of research on health gradient has examined the association between socioeconomic well-being of individuals and various indicators of health within specific countries. These studies have repeatedly found that individual socioeconomic status—measured either by income, occupational status or education—is positively associated with health—measured by various health indicators, including self-reported health, measures of physical and mental illness, long-term disabilities, functionality

Research questions and hypotheses

The major purpose of this study is to answer the following questions: First, is household wealth positively associated with the personal health of older individuals net of their education and socio-demographic attributes? Second, does household wealth contribute to health net of a household income level, education and socio-demographic characteristics? Third, is a country's healthcare system type likely to affect the health of its older population? Finally, is a country's healthcare system type

Healthcare dimension indicators

Data for the dimension indicators were obtained from the health system reviews of the European Observatory on Healthcare Systems and the Organization for Economic Co-operation and Development (OECD) (see Appendix 1).

Individual-level data

The data were obtained from three projects: The Survey on Health, Ageing and Retirement in Europe (SHARE; Börsch-Supan and Jürges, 2005); the U.S. Health and Retirement Study (HRS; Juster and Suzman, 1995, Health and Retirement Study, 2004); and the English Longitudinal Study of

Cross-country mean differences in health

Fig. 1 demonstrates the average severity-weighted index values by countries. The results presented in Fig. 1 reveal significant variation across countries in the physical health level. On average, the older population in the U.S. has the poorest level of physical health (80.42), about 11 points lower than in the U.K., whose population reports the highest level of physical health (91.04). The estimated average physical health in Germany (90.29) and Sweden (90.32) is quite similar. In the Czech

Discussion and conclusions

First, in line with previous studies, the results indicate that economic well-being is likely to increase the health of older people, net of their socio-demographic attributes and education; that is, household wealth and income exert a positive and statistically significant effect on health. Notably, however, the association between wealth and health was found to be largely independent of income. Although the association between wealth and health outcomes was slightly attenuated after

Acknowledgments

I am grateful to Professor Moshe Semyonov, Professor Noah Lewin-Epstein, and the anonymous reviewers of Social Science & Medicine for their helpful comments on the earlier drafts of this paper.

This work was supported by the German-Israeli Foundation for Scientific Research and Development (G.I.F.; Grant #1021-305.4/), the Israel National Institute for Health Policy and Health Services Research, Myers-JDC-Brookdale Institute of Gerontology and Human Development, and Eshel – the Association for

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